1053133710 NPI number — JERSEY SHORE SPINE LLC

Table of content: (NPI 1053133710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053133710 NPI number — JERSEY SHORE SPINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JERSEY SHORE SPINE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053133710
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20 CHERRY TREE FARM RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07748-2251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-615-9420
Provider Business Mailing Address Fax Number:
732-615-9427

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9 HOSPITAL DR STE B4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOMS RIVER
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08755-6425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-615-9420
Provider Business Practice Location Address Fax Number:
732-615-9427
Provider Enumeration Date:
10/24/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DUGO
Authorized Official First Name:
JACK
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
732-996-6643

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)